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Prevention and Management of Malaria during Pregnancy: Findings from A

Comparative Qualitative Study in Ghana, Kenya, and Malawi
Disusun untuk memenuhi tugas kepaniteraan klinik

SMF Ilmu Obsteri dan Ginekologi
RSD dr. Soebandi Jember
Disusun oleh
Bagaskoro Gigih Prakoso
112011101047
Pembimbing
dr. Gogot Suharyanto, Sp.OG
FAKULTAS KEDOKTERAN UNIVERSITAS JEMBER

LAB/SMF ILMU OBSTETRI DAN GINEKOLOGI
RSD DR. SOEBANDI JEMBER
2015
Pell et al. Malaria Journal 2013, 12:427

http://www.malariajournal.com/content/12/1/427
RESEARCH
Open Access
Prevention and management of malaria during

pregnancy: findings from a comparative
qualitative study in Ghana, Kenya and Malawi
Christopher Pell1,2*, Arantza Meaca2,3, Nana A Afrah4, Lucinda Manda-Taylor5, Samuel Chatio6, Florence Were7,
Abraham Hodgson8, Mary J Hamel9, Linda Kalilani5, Harry Tagbor4 and Robert Pool1,2
Abstract
Background: In endemic regions of sub-Saharan Africa, malaria during pregnancy (MiP) is a major preventable
cause of maternal and infant morbidity and mortality. Current recommended MiP prevention and control includes
intermittent preventive treatment (IPTp), distribution of insecticide-treated bed nets (ITNs) and appropriate case
management. This article explores the social and cultural context to the uptake of these interventions at four sites
across Africa.
Methods: A comparative qualitative study was conducted at four sites in three countries: Ghana, Malawi and Kenya.
Individual and group interviews were conducted with pregnant women, their relatives, opinion leaders, other
community members and health providers. Observations, which focused on behaviours linked to MiP prevention
and treatment, were also undertaken at health facilities and in local communities.
Results: ITNs were generally recognized as important for malaria prevention. However, their availability and use
differed across the sites. In Malawi and Kenya, ITNs were sought-after items, but there were complaints about availability. In central Ghana, women saved ITNs until the birth of the child and they were used seasonally in northern
Ghana. In Kenya and central Ghana, pregnant women did not associate IPTp with malaria, whereas, in Malawi and
northern Ghana, IPTp was linked to malaria, but not always with prevention. Although IPTp adherence was common
at all sites, whether delivered with directly observed treatment or not, a few women did not comply with IPTp often
citing previous side effects. Although generally viewed as positive, experiences of malaria testing varied across the
four sites: treatment was sometimes administered in spite of a negative diagnosis in Ghana (observed) and Malawi
(reported). Despite generally following the advice of healthcare staff, particularly in Kenya, personal experience, and
the availability and accessibility of medication including anti-malarials influenced MiP treatment.
Conclusion: Although ITNs were valued as malaria prevention, health messages could address issues that reduce
their use during pregnancy in particular contexts. The impact of previous side effects on adherence to IPTp and
anti-malarial treatment regimens during pregnancy also requires attention. Overtreatment of MiP highlights the
need to monitor the implementation of MiP case management guidelines.
Keywords: Malaria, Pregnancy, IPTp, Insecticide-treated bed nets, ITNs, Malaria case management
* Correspondence: c.l.pell@uva.nl
1
Centre for Social Science and Global Health, University of Amsterdam,
Amsterdam, The Netherlands
2
Centre de Recerca en Salut Internacional de Barcelona (CRESIB, Hospital
Clnic-Universitat de Barcelona), Barcelona, Spain
Full list of author information is available at the end of the article
2013 Pell et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication
waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise
stated.

Background
In endemic regions of sub-Saharan Africa, malaria during
pregnancy (MiP) is a major preventable cause of maternal
and infant morbidity and mortality [1]. Malaria during
pregnancy compounds or provokes anaemia, which, when
severe, increases the risk of maternal death (estimated at
around 10,000 deaths annually [2]). Low birth weight
(linked to around 100,000 annual infant deaths in Africa
[2]), pre-term delivery, congenital infection and reproductive loss are also linked to MiP [3]. Nonetheless, in spite of
its associated high burden of morbidity and mortality,
MiP was, until recently, recognized as a neglected area of
research [4].
Current recommended MiP prevention and control
strategies in areas of stable moderate to high malaria transmission include the administration of intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine
(SP), distribution of insecticide-treated bed nets (ITNs)
and appropriate case management [5]. Despite the progress made in the last decade, the coverage of IPTp and
ITNs amongst pregnant African women remains inadequate [6]. For proper case management, the most appropriate treatment depends on the malaria species, severity
of infection, local patterns of drug resistance, drug availability and gestational age [7]. This, combined with incomplete MiP surveillance data across sub-Saharan Africa [5],
complicates estimates of appropriate case management.
Nevertheless, given the insufficient availability of diagnostic
tests and artemisinin-based combination therapy (ACT)
[5] (recommended as first-line treatment for MiP during
the second and third trimester), case management is likely
to be sub-optimal.
In response to the challenges of MiP prevention and
control, a research consortium of 47 partner institutions
in 32 countries, was established and is currently conducting a wide range of scientific activities in Africa,
Asia, Australasia (Papua New Guinea) and South America
[8]. The MiP Consortium takes a multi-disciplinary approach to MiP, bringing together immunologists, epidemiologists, public health experts and social scientists.
This paper draws on the results of an anthropological
programme of research that forms part of the consortiums Public Health Impact Group.
The overall goal of the anthropological research carried out under the auspices of the MiP Consortium is to
contribute to the development and implementation of
appropriate MiP interventions by gaining an in-depth
understanding of the social and cultural context of MiP.
A review of previously conducted research identified
four broad topics that influence the uptake of MiP interventions [9]: concepts of malaria and risk in pregnancy;
attitudes towards malaria prevention and treatment; perceptions of antenatal care (ANC) services; and structural
factors. These four themes have been widely explored by
Page 2 of 13
the MiP Consortiums Anthropology Team. This article

focuses on attitudes towards MiP prevention and management (testing and treatment); two separate articles
focus on attitudes towards concepts of malaria and risk
during pregnancy [10] and perceptions of ANC [11].
The analysis of the structural factors affecting MiP prevention and control is integral to all three articles.
In recent years, the malaria research and policy community has increasingly emphasized accurate diagnosis to ensure appropriate treatment of malaria. In the absence of
diagnostic tests, malaria is commonly over-diagnosed because of its non-specific symptoms: headache, fatigue, abdominal pain, muscle and/or joint aches, fever, chills,
perspiration, vomiting and malaise [12]. Therefore, as a result of concerns about overuse of malaria drugs, the 2010
WHO Guidelines for the treatment of malaria recommended diagnosis by microscopy or rapid diagnostic test
(RDT) for all persons suffering from suspected malaria
prior to treatment [12]. Moreover, there is overlap between malaria and womens other health complaints during pregnancy. Thus diagnostic confirmation of MiP is
particularly important for appropriate management [13]
and is a key issue for this article.
To provide insight into the social and cultural context
to the uptake of interventions for malaria prevention
and control, this article addresses the following research
questions: what are the attitudes and behaviours towards
MiP prevention and management amongst pregnant
women, healthcare staff and other community members
in four sites in Ghana (northern and central), Kenya
(Nyanza Province) and Malawi (southern region); how
does the social and cultural context influence these attitudes and behaviours; and what are the implications of
the attitudes and behaviours for the design of effective
MiP interventions? To identify and examine relevant issues that might otherwise be taken for granted, a comparative approach is taken and data are presented from
four sites.
Methods
The results presented in this article are drawn from a
comparative study conducted at four sites in three
countries. The study was undertaken by a team of researchers whose members were based across the sites
and in Barcelona (Spain).
Settings
The study incorporated one country from each of the

three main regions of Sub-Saharan Africa: Ghana in West
Africa, Kenya in East Africa and Malawi in Southern
Africa. Two sites with important regional specificities
were selected in Ghana for several reasons: to collect
data in at least one site of each of the MiP Consortiums
main treatment and prevention activities; to include areas

Page 3 of 13
with different patterns of malaria transmission; and to

examine intra as well as inter-country variation.
In central Ghana, fieldwork was conducted in two districts of the Ashanti Region: Ejisu Juaben and Ahafo
Ano South. In both districts, agriculture is the main productive activity and there is a significant proportion of
internal migrants, in addition to the majority ethnic
group, the Asante [14]. At this site, malaria transmission
is moderately high and occurs throughout the year with
peaks during the rains in May-October [15]. In each district, data collection was conducted at the district hospitals, two to three health centres and several smaller
clinics.
In northern Ghana, Upper East Region, the fieldwork
sites were located in Kassena-Nankana District. This
area is part of the Sahel and experiences only one annual
rainy season during which people grow millet, maize
and vegetables for subsistence. During the rest of the
year, part of the population migrates to other regions.
The Kassena and the Nankani, make up almost 90% of
the population of the district [16]. Here, malaria transmission is perennial but there is a seasonal pattern with
a transmission peak that coincides with the major rains
(May to October) and the low rates of infection during
the dry season [17]. Data were collected at a district hospital in Navrongo, (the capital), and outreach communitybased services, which are common throughout the area.
Fieldwork also took place in Chikwawa and Blantyre
Districts, in the southern region of Malawi. The main
ethnic groups in Blantyre District are Chewa and Yao,
whereas in Chikwawa they are Manganja and Sena. Most
of the women in the area cultivate crops for subsistence
and sale at the market. Both districts are in areas of high
perennial malaria transmission [18]. Fieldwork took place
at three hospitals, and six healthcare centres that provide
ANC services to the women in these areas.
Finally, in Kenya, fieldwork was carried out in Siaya
District (Nyanza Province) where the principal ethnic
group, the Luo, make up over 95% of the population.
Livelihood activities include subsistence farming of maize,

sorghum, millet and cassava. As a result of the relatively
limited employment opportunities, migration to urban
centres is common, particularly to Kisumu, the nearest
city. Malaria transmission is high and perennial [19] with
the greatest disease burden borne by children and pregnant women. Data were collected at the district hospital
and smaller health facilities where ANC is delivered.
At each of the sites, various clinical and non-clinical
studies of MiP prevention and control interventions
have been undertaken. Some of these studies overlapped
with data collection for this research. Therefore, during
data collection and analysis, efforts were made to exclude
experiences of MiP prevention and control within clinical
or non-clinical research. Furthermore, throughout this
article, for reasons of brevity, the sites are referred to as
Kenya, Malawi, central Ghana and northern Ghana.
This shorthand should not however be interpreted as any
attempt at regional or national generalization.
Data collection
An anthropological approach was taken to data collection.

This entailed year-long (or longer) periods of fieldwork at
each site, a range of data collection activities, including
narrative and observational techniques (see Table 1 for a
full list of data collection activities), and a flexible, reflexive
and iterative process of tool design, data collection, and
analysis. The use of multiple data collection tools with
heterogeneous respondents ensured that findings could be
triangulated and their reliability tested. To reduce the possible influence of individual bias on the study findings, at
each site, several researchers collected data.
Fieldwork was carried out between April 2009 and August
2011, and lasted from one year in Malawi to more than
two years in central Ghana. Assisted by two Barcelonabased researchers (AM and CP), fieldworkers spent extended periods of time in the settlements where data were
collected and recorded their experiences of participant observation in field diaries. In the first phase, at each site,
Table 1 Respondents
Data collection activities
Respondent type
Central Ghana
Northern Ghana
Kenya
Malawi
Total
Free listing and sorting
Community members
12
16
17
24
59
Pregnant women
10
10
11
38
Health providers*
10
11
32
Pregnant women
84
64
69
68
285
Health providers*
33
34
17
21
105
In-depth interviews
Relatives
26
29
20
16
91
Opinion leaders
12
12
10
12
46
Case studies
Pregnant women
19
18
12
18
67
Focus group discussions
Community members
10
16
16
51
*Includes healthcare staff involved with the provision of ANC at health facilities and TBAs working in the communities.

using free-listing and sorting exercises, the research team

explored the main problems that pregnant women experience. Later, interviews and group discussions were conducted, several women (case studies) were followed and
interviewed several times over the course of their pregnancies, and observations were carried out in the communities and at local health facilities. The language used to
interact with informants depended on their preferences
(English and different local languages). In-depth interviews and group discussions were recorded, transcribed
and translated into English.
In-depth interviews tended to start with broad research questions related to pregnancy and ended with
questions about malaria in pregnancy and experiences
with malaria prevention and control. In contrast, group
discussions often started with general questions about
malaria, focusing later on groups particularly vulnerable
to malaria and finalizing with malaria prevention and
control. Other themes, related to MiP, such as miscarriage, stillbirths, pre-term deliveries, birth weight and
anaemia and their causes were also explored during
fieldwork. Data collection and analysis were carried out in
parallel allowing the incorporation of emerging themes in
the design of the tools, and questions redefinition and
attuning.
Members of the Barcelona-based research team made
quarterly visits to the study sites. During these visits, a
process of debriefing and reflection took place with
fieldworkers. The Barcelona-based researchers were also
able to participate in data collection, and provide ongoing
training.
Respondents
Five main categories of respondents were interviewed

(Table 1): pregnant women, their relatives, community
members, opinion leaders and healthcare providers. Purposive sampling was used to ensure the interaction with
a wide range of experiences. Married and unmarried
pregnant women of a range of ages, parities and gestational ages from across the different settlements (within
the field sites) were interviewed. Relatives included
mainly mothers, mothers-in-law and husbands of the
pregnant women. The sample of opinion leaders was
made up of a variety of religious leaders, traditional and
political authorities, and relevant women in the local
communities. Finally, ANC staff, pharmacists and drug
sellers, traditional birth attendants (TBAs), and other
healers (who attended to pregnant women or dealt with
malaria) were interviewed at each site. Respondents were
identified in ANC clinics and via contacts in the local
communities, which developed as fieldwork went on.
The final number of participants was a result of the directed sampling and the point of saturation, whereby no
further novel insights were identified from interviews.
Page 4 of 13
Data analysis
At each site, a first phase of data analysis ran in parallel

to data collection. Using Atlas.ti 6, flexible codebooks
were developed and revised using a combination of
established categories based on the original research
questions and themes that emerged from the data. Particular attention was paid when analyzing the interviews
with case studies to identify changes in a womans responses over the course of her pregnancy, for example,
with regard to ITN use. The preliminary results obtained
from this site-specific analysis were compared and discussed amongst the members of the team in periodic
meetings throughout data collection. In a second phase,
data associated to the codes relevant to malaria in pregnancy perceptions, were extracted, collated and discussed
between authors one and two, looking at the similarities,
differences and variations between and within the different
sites.
Ethics statement
Overall ethics clearance was obtained from the Clinical

Research Ethics Committee, Hospital Clinic-University
of Barcelona. Separate local ethics clearance was obtained at each site: in Ghana, clearance was obtained
from the Institutional Review Board of the Navrongo
Health Research Centre, Navrongo and the Committee
on Human Research Ethics, Kwame Nkrumah University
of Science & Technology, Kumasi; in Kenya, clearance
was obtained from the Institution Review Board of Centers for Disease Control and Prevention, Atlanta and
from the National Ethics Review Committee, Kenya
Medical Research Institute, Nairobi; and in Malawi,
clearance was obtained from the College of Medicine
Research and Ethics Committee. As approved by all
ethics review committees and institutional review
boards, informed consent was obtained orally from study
participants. Oral rather than written informed consent
was obtained because the study procedures posed minimal risk to study participants and to avoid the possible
negative influence of a written consent on rapport between researchers and respondents. With the agreement
of participants, verbal consent was voice recorded prior
to each interview or focus group discussion.
Results
Prevention
ITNs
Sleeping under an ITN was generally recognized as the

main way to prevent malaria (or the local illnesses that
overlapped with biomedically defined malaria at each
site, which, although not addressed specifically here, are
discussed in a separate article [10]). The availability and
use of ITNs however differed across the four sites (see
Table 2).

Page 5 of 13
Table 2 Insecticide-treated bed nets (ITNs) for pregnant women: policies, availability and preferences
Site
Policy
Shortages
Availability and use
Kenya
Free delivery at health facilities
No
Pregnant women report sleeping under ITNs

Pregnant women claim ITNs are not provided
Observations in houses confirm presence of ITNs
Malawi
Free delivery at health facilities
Observed
Pregnant women report sleeping under ITNs
Ghana (northern)
Sold in health facilities at subsidized prices
Observed
Cases of seasonal use of ITNs
Ghana (central)
Sold in health facilities at subsidized prices
No
Pregnant women complain about costs of ITNs
Availability and access of ITNs
In Ghana, ITNs were sold in the health centres at ANC

at a subsidized price but purchases were rarely observed.
Moreover, in Northern Ghana, shortages of nets were
encountered. No national mass ITNs distribution campaigns were observed during fieldwork, however, a nongovernmental organization distributed free ITNs to the
local population and a limited number of our informants
in northern Ghana received an ITN.
In Malawi, insecticide-treated bed nets were distributed
free of charge to pregnant women at health facilities on
two occasions: at first ANC visit, and once after delivery.
Observed shortages however supported pregnant womens
claims of not always receiving an ITN. Bed nets were
sought-after items in Kenya and, although healthcare staff
reported providing ITNs to all women who attend ANC
(and observations suggested that they were plentiful at
health facilities), there were complaints from pregnant
women of ITNs not being handed out as part of ANC.
Pregnant women report saving for use after delivery
netting, fishing nets, latrine doors, crop protectors and

decorative wall hangings.
During fieldwork, there were also very scattered reports of opinions that might deter women from sleeping
under ITNs. In Kenya, there were infrequent references
to feeling hot and suffocated when under the ITN, and
similar comments about heat discouraging people from
sleeping under ITNs in Malawi and Ghana. In Malawi
and Ghana, although rare, criticisms were made of the
insecticides used to treat the ITNs.
IPTp
Availability of IPTp
Policies regarding IPTp delivery varied across the sites:

in Malawi, women were to be administered two doses of
IPTp, whereas, in Ghana, policy stipulated a three-dose
regimen. In Kenya, at least two doses were to be delivered
at monthly intervals after quickening. At all sites, shortages of SP for IPTp were not encountered and healthcare
staff described them as exceptional occurrences.
ITN ownership and use
At all sites, pregnant women reported a demand for

ITNs. Although they complained about their price,
Ghanaian women reported sleeping under ITNs. However, in central Ghana there were women who, in spite
of owning an ITN, only used it after giving birth; these
women considered their newborns to be at greater risk
of malaria and also valued new possessions to mark the
birth of a child. In northern Ghana, women used ITNs
in the wet season because mosquitoes were present and
they slept indoors. However, in the dry season, due to
the heat, outside sleeping was the norm and ITNs were
therefore not used. In Kenya and Malawi, although
household sleeping arrangements and the lack of space
in dwellings prevented some pregnant women from
sleeping under ITNs (particularly if children were given
priority), respondents generally reported that they used
their ITNs, sometimes sleeping alongside their youngest
children. Moreover, in Kenya, ITNs were often directly
observed hanging in respondents dwellings. The value
that Kenyan respondents placed on ITNs was also linked
to their observed multiple uses: for example, as garden
Knowledge of IPTp
In central Ghana and Kenya, pregnant women did not

usually associate IPTp with malaria, whereas, in Malawi
and northern Ghana, IPTp was associated with malaria,
but not always with prevention. In central Ghana, only a
minority of pregnant women recalled being given pills to
prevent malaria; when probed about the tablets that they
received during ANC visits, the majority did not know
what they were for or interpreted them as intended for
general pregnancy care. Moreover, younger mothers
were less aware of the drugs provided.
Interviewer (I): Why do you think they gave you those
three medicines?
Respondent (R): I didnt ask them. When they gave
them to me, I took them over there. So
I didnt ask them why they gave them
to me but I know they gave them to me
because of the pregnancy.
(Central Ghana, in-depth interview with a pregnant
woman, 24 years old, one child)

Kenyan pregnant women were often unfamiliar with

IPTp as malaria treatment or prevention. Although a
small minority of respondents recalled taking Fansidar
(the brand name for SP) during ANC visits to prevent
malaria, those who did not, when probed about the
white tablets supplied during ANC, reported that they
were de-worming tablets, tablets to cure their (mild)
malaria/fever, multi-vitamins or they simply did not recall
receiving them (in spite of healthcare staff reporting that
all women receive IPTp). Although a lack of communication between healthcare staff and pregnant women during
ANC was observed at this site (and at other sites), the
Kenyan women who said that they asked health care staff
specifically about the white tablets reported that they received information.
In northern Ghana, there was greater awareness of
malaria drugs being administered during ANC: around
half of the interviewed pregnant women referred to the
malaria drugs, but most were unaware that they were
intended as prevention. Pregnant womens knowledge of
IPTp was also high in Malawi: most respondents were
familiar with Fansidar as an anti-malarial drug given to
pregnant women and, when administered during ANC,
it was considered to provide protection from malaria for
the mother and the unborn child and/or treatment for
the pregnant womans malaria.
I: What about the Fansidar they gave you, what was it
for?
R: It protects against malaria but also deals with
general body pains.
(Malawi, in-depth interview with a pregnant woman,
25 years old, two children)
Attitudes towards IPTp
The lack of awareness of IPTp in Kenya and central

Ghana complicated attempts at assessing attitudes to
IPTp or SP. However, regardless of whether pregnant
women were familiar with IPTp, complaints of side
effects linked to the medication received during ANC
visits (largely nausea and dizziness) were uncommon
at these sites. In Malawi and Northern Ghana, direct
complaints about side effects of IPTp, especially
vomiting, were more common. This was in spite of
womens greater efforts to reduce the possibility of
side effects at these sites: here, women were often advised by healthcare staff to eat a meal before receiving
IPTp to prevent nausea or vomiting. These complaints
did not however necessarily lead to non-compliance
because IPTp was generally accepted (albeit sometimes begrudgingly) as part of the package of ANC
interventions, which was collectively viewed in a
positive light.
Page 6 of 13
I: Do you think that those medicines have disturbed

some pregnant women?
R: Yes, some women swallow and go out and vomit it
away but I have never swallowed it and vomited it out.
(Northern Ghana, in-depth interview with a pregnant
woman, 22 years old, one child)
IPTp-related behaviours
Observations highlighted how IPTp was not universally

administered according to the directly observed treatment (DOT) protocol. This was often a result of
drinking-water being only available outside of the consultation room: freely available from drinking fountains
in communal spaces or purchased from vendors on or
close to the health facility premises. However, at one
health facility in central Ghana, DOT was contingent on
other factors: prior to administering IPTp, healthcare
staff first enquired whether pregnant women had eaten.
If they had eaten prior to attending the health facility,
the SP was administered during the consultation under
DOT. However, if they had not eaten, the women were
instructed to take the SP away with them and to take it
after eating. These staff, therefore, prioritized the Ghanaian
policy guideline that stipulates women should have eaten
prior to receiving SP (which is contradicted by more recent WHO guidelines [20]) over that which specifies DOT
for IPTp [21].
Instances of IPTp non-adherence were however encountered. In Kenya, for example, DOT was not always
followed because the drinking water fountain was located in the waiting area and a woman was observed
slipping her tablets into her handbag on leaving the consultation room). When asked about this, she explained
her non-adherence in terms of previous experiences of
vomiting after taking the same tablets. She was also unaware of the purpose of the medication. At the other
sites, there were also indirect reports (and one direct) of
non-adherence, and the following quotation hints at
non-adherence occurring even in cases of DOT.
I: Were you given some drugs to take instantly at the
initial visit?
R: Yes
I: What was the colour?
R: White
[]
I: Were you told what it was meant for?
R: No
[]
I: Did you have any problems when taking them?
R: I always vomited
[]
I: Did you tell [the healthcare staff] that the medicine
was making you vomit?

R: No
I. So did you take them and vomit again?
R: I didnt take them again even though I was given
them.
I: But you are always asked to take them straight away?
R: I was given the drugs and water to take but I kept
[the tablets] in my purse.
I & R: [Laughter].
(Northern Ghana, in-depth interview with a pregnant
women between 20 and 25 years old, one child)
Generally though, according to healthcare staff and
pregnant women, even without DOT and even though
they may have been unaware about the name or purpose
of the medication, women took the SP when it was given
to them. This was even the case in both sites in Ghana,
where women had to buy water to swallow the tablets
from vendors in health facilities for a small fee (US
$0.05) that women viewed as an insignificant part of the
total cost of ANC (including transport costs etc.). Indeed, during ANC visits, women followed instructions
from healthcare staff that provided the interventions
(see [11] for further details regarding ANC attendance).
Case management
Malaria diagnostic tests
Although generally positive, attitudes towards and

awareness of malaria testing varied across the sites. Pregnant women, and the community in general in central
Ghana, accepted healthcare staff as providing accurate
diagnoses of their health complaints, whether blood analyses were carried out or not. Women could however
not always recall the purpose of the tests for malaria
or otherwise during clinic visits.
I: How would you know a pregnant woman has
malaria?
R: It is only when she goes to the hospital would they be
able to tell whether she has malaria or not because
pregnant women are often weak. So you might even
think she is sick when she is not.
(Central Ghana, in-depth interview with the husband
of a pregnant woman, 35 years old)
In northern Ghana, pregnant women identified contradictions between the messages provided in health facilities and their own experiences of malaria: some women
complained of being frequently told that malaria was the
reason they were feeling unwell, whereas, on other occasions, they thought that they had malaria but were not
given treatment. As the quotation below suggests, ambiguity was often linked to the breadth of the local illness
concept that approximated to biomedically defined malaria (as is discussed in more detail elsewhere [10]).
Page 7 of 13
I: Did you not have malaria at a point in time?

R: Ok. There was a time when I went and told [the
healthcare staff] that I had malaria and they told me
that we should not always say that we have malaria,
but we should just say that we are sick, because we
cannot tell whether it is malaria or not. But I know
that I had malaria because I was vomiting.
I: Did they give you any malaria drugs?
R: Yes they gave me some. They made me go and do
some test before they gave me that medicine.
(Northern Ghana, an in-depth interview with a pregnant woman, 29 years old, one child)
At both sites in Ghana, health professionals described
the importance of diagnostic tests for accurate malaria
diagnosis. In these settings, however, health professionals
also explained that infants and pregnant women were
exceptions to the new policy on malaria case management that stipulated a positive malaria test prior to administering anti-malarials. Hence, pregnant women were
observed receiving anti-malarials without being tested
(even if a test was available) or despite a negative malaria
test result.
In Malawi, pregnant women viewed malaria diagnostic
tests as ambiguous. Although not always available, when
they were available, positive results were often trusted
and seen as confirmation of a diagnosis. In cases of a
negative result, the test was sometimes viewed as missing the infection. The subsequent lack of treatment also
disappointed women who had assumed that they were
suffering from malaria and expected to be treated. However, the following quotation from a focus group is one
example of the reports of treatment in spite of a negative
test result.
I: Can one have malungo (malaria) without knowing?
All: Quite.
[]
R5: We get tested and then you know that you have
malungo even when you go [to the clinic] for
another disease and not malungo.
I: Is it possible to feel that you have malungo and at the
hospital they do not find it?
R1: Yes, its possible.
All: Yes.
I: So what happens when you have all the symptoms
and they do not find the malungo?
R5: They give AL (artemether-lumefantrine).
All: Yes.
(Malawi, a group discussion with local women)
In contrast, interviewed Malawian healthcare staff only
referred to treating after a positive result. Moreover, malaria-like symptoms were said to be common amongst

pregnant women, but the rapid diagnostic test confirmed a

minority of these cases as malaria (one health worker referred to one in ten).
Kenyan respondents generally valued diagnostic tests
for malaria (and other diseases): they viewed them as accurate and associated them with more effective treatment. Indeed, one pregnant womans husband stressed
the need to travel the extra distance to the district hospital to ensure access to diagnostic tests. Nonetheless,
respondents described having malaria, particularly mild
malaria, without having obtained a diagnosis (either
from a health worker based on clinical presentation or
the result of a blood test). This was linked to the broad
illness category of malaria that respondents described,
which did not necessarily match the biomedical definition
[10].
For the most part, malaria tests were only available
free of charge through the laboratories of medical research institutes that were carrying out clinical studies
within the grounds of health facilities. In smaller health
centres, a malaria test was only available with the assistance of staff from the medical research institutes, who
tested non-study patients when requested by healthcare
staff or when severe malaria was suspected. At the district hospital, although malaria tests were sometimes
available in the Ministry of Health laboratory, charges
were commonly levied for these tests. There were therefore reports of healthcare staff administering anti-malarials
without a test.
Sometimes you may go to these [drug] shops and tell
them your problems for example, I have a headache
but they will not do a lab test so they will just give you
medicine thinking that it is malaria but it is not. Now
it is good to go to the hospital and get tested so that
you may know the problems that you are suffering
from
(Kenya, in-depth interview with a pregnant woman,
20 years old, two children)
Indeed, Kenyan healthcare staff viewed malaria
symptomatic and asymptomatic as common amongst
pregnant women. In light of this, a diagnostic test was
viewed as essential to confirm the diagnosis.
R: At least, out of all the admissions, you will find that
eight out of ten will have malaria. Almost all. And
half of them never feel ill. So when you take the
temperature that is when you realise but they dont
complain. You see the [blood] slide.
I: So you are saying that eight out of ten have malaria
and most of them are not complaining.
R: Yeah most of them dont complain, they just see it as
part of the discomfort of pregnancy but when now
Page 8 of 13
you are doing your research, and doing the blood

tests, they will say ah, I dont even have malaria,
and you say lets check. And you check and you will
see and have to treat, so thats malaria.
(Kenya, in-depth interview with a healthcare provider)
Treatment
Type of anti-malarials
Across the four sites, all respondent types viewed biomedicine as the primary treatment option for malaria,
particularly severe malaria. Although some herbal remedies were described, respondents reported their use to
be infrequent. In Malawi, references to non-biomedical
treatments for malaria were very scarce. In Kenya, poverty was said to be a reason for pregnant women using
herbal remedies as a last resort for malaria. In central
Ghana, herbal malaria remedies were used, particularly
in rural areas by uninsured adults (to avoid the costs of
both transport and medical care) and on other occasions
for cases of mild malaria in addition to biomedical treatments. At this site, the use of non-biomedical remedies
during pregnancy was common to ensure a safe delivery
and a healthy baby. However, no remedy specifically for
MiP was reported. In northern Ghana, adults and children were regularly given herbal malaria treatments, but
pregnant women did not use them because of their bitter taste, which was viewed as a cause of miscarriage.
I: Is there herbal medicine for paa (malaria)?
R: Yes it is there, but in this community they hardly give
herbs to pregnant women, because they are afraid,
they dont know what is inside the stomach.
I: If you are not pregnant and you have paa, can you
use the local medicine?
R: Yes, you can use the soli, a long tree, and boiled
neem leaves. You use it to cover yourself, drink and
bathe.
(Northern Ghana, In-depth interview with a pregnant
woman, more than 35 years old, 4 children)
Availability of and access to anti-malarials
Anti-malarials, including SP, were available in drugstores

at both sites in Ghana. However, during fieldwork there
were no reports or observations of pregnant women
buying them; in theory, health care is free to pregnant
women (though they sometimes are faced with charges
[11]) and they therefore preferred to seek care at health
facilities. In Malawi, ACT was not easily available, except
in health facilities. Moreover, although at the beginning
of fieldwork, SP was available in grocery shops, it was
later prohibited and therefore increasingly unavailable as
stocks ran out. In both countries, women acknowledged
buying and taking painkillers, mainly paracetamol, without prescription for mild symptoms of pregnancy and/or

malaria. In Kenya, the majority of pregnant women and

other respondents maintained that pregnant women
should to go to clinic to be prescribed drugs for (especially severe) malaria. However, women admitted having
bought drugs from local pharmacies without a prescription or taking other medication that was not prescribed
for them (due to the mildness of the malaria, the high
price of the drugs recommended by healthcare staff, or a
reluctance to visit a health facilities, because of cost or
other reasons).
Knowledge and understandings of anti-malarials
In Ghana, pregnant women did not recall the names of

anti-malarials, but some could describe the colours of
the tablets, the doses and/or the packaging. In Malawi,
the names of anti-malarials were used even if respondents identified them incorrectly. Malawian respondents
also viewed the effectiveness of a particular anti-malarial
as dependent on the individual: certain tablets were said
to suit some individuals better than others. And there was
a reasonable consensus amongst respondents regarding
which malaria medicines (even if not anti-malarials)
were appropriate for pregnant women: Fansidar (SP)
was mainly considered the anti-malarial for pregnant
women and a small proportion of pregnant women
stated that artemether-lumefantrine (AL), quinine, bactrim, penicillin and ibuprofen were too strong to be
used during pregnancy and that they can harm the unborn child. Other women accepted AL as treatment for
pregnant women, provided that it suits the individual.
There were Kenyan respondents who recounted a list of
drugs to treat malaria and others who only mentioned
one or two. Their lists included painkillers or cold remedies, often intended for mild illness episodes that were
labelled using the local illness that overlapped with biomedically defined malaria [10]. Indeed, across all the sites,
women reported using paracetamol (often termed panadol or para) and aspirin for mild symptoms of pregnancy
and/or malaria. There were even reports of Ibuprofen use
during pregnancy. Kenyan women also mentioned Coartem (AL) and quinine, which tended to be associated with
severe malaria. Respondents had varied opinions about taking malaria drugs during pregnancy: there were reports
of a need to consult healthcare staff, yet there were also
cases of pregnant women self-medicating with antimalarials. One woman was unsure about taking bitter
drugs during pregnancy and another was wary about taking many drugs.
Although women generally reported following the advice
of healthcare staff, in Kenya, the availability and accessibility of medication including anti-malarials could influence where women received treatment. For example, one
Kenyan woman attended a health facility for an acute illness and sought assistance where ANC is normally
Page 9 of 13
provided. However, ANC was not offered at that time, and

the healthcare staff who examined her instructed her to
pay for the anti-malarials. Unable to pay, she visited a drug
store where she bought drugs more cheaply. Such examples were however not observed nor reported in Malawi
or Ghana. Furthermore, in general, although compliance
with anti-malarial treatment regimens was not observed
directly, Kenyan womens reports of anti-malarial use varied: there were at least two reports of women using ACT
that they already had at home, for example, that had been
previously prescribed to a young child. Some women however emphasized the need to follow the instructions from
healthcare staff because of the dangers of taking medication during pregnancy.
In Ghana, the side effects of anti-malarials and the advice of health staff influenced whether pregnant women
completed the prescribed treatment course. In total,
four women were identified who did not complete their
prescribed treatment courses. For one of these women,
a health workers advice about sweetening medication
caused confusion: the woman associated the sweet taste
with malaria and was therefore deterred from completing the treatment course. In both Ghana and Malawi,
health talks and the advice given individually to pregnant
women at ANC included warnings about self-medication
and healthcare staff expressed concerns about the use of
non-prescribed drugs and traditional remedies. However,
in Ghana, health messages did not focus on adherence to
prescribed anti-malarial regimens.
Discussion
Across all the sites, respondents recognized that sleeping
under an ITN was a way of preventing malaria. Even
though respondents at all sites offered additional explanations (such as poor hygiene) for a bout of malaria (or
the local illness that overlapped with biomedically defined malaria (see [10] for further details), mosquitoes
were reported to be the main cause. The connections
that respondents made between ITNs use and malaria
prevention were therefore unsurprising. Malaria was also
viewed as a common disease for pregnant women, and
considered to be a cause (along with other contributing
factors) of miscarriage [10].
In addition, negative attitudes towards ITNs were rare
and there were no specific objections to their use during
pregnancy. This finding, in varied social and cultural
contexts with different mechanisms of ITN distribution,
contrasts with several previous studies that have highlighted health concerns linked to ITN use during pregnancy, particularly with regard to the impact of the
insecticide treatments on the unborn child [22-25].
These studies were carried out prior to the distribution
of long-lasting ITNs and it was often the insecticide, and
process of re-treatment, that provoked such concerns.

One multi-site study in Kenya highlighted additional

negative attitudes towards ITNs including complaints
about distribution campaigns targeting pregnant women
and infants [26]. Such comments were attributed to a lack
of information linking increased malaria vulnerability with
ITN distribution [26]. By contrast, respondents in this
study often highlighted pregnant womens increased risk
malaria [10] and no such negative comments about the
targeting of pregnant women were encountered.
The broader meanings associated with ITNs had varying implications for their use. In central Ghana, women
viewed ITNs as a consumer good and therefore left them
unused during pregnancy, hanging them up for the first
time to mark the birth of the child. Kenyan respondents
also valued ITNs as a household item with multiple uses,
such as protecting crops from birds. However, in this
context, the multiple uses of ITNs did not necessarily
prevent pregnant women from sleeping under them.
These findings are a reminder of how health technologies (in this case, intended by its designers for malaria
prevention) can take on quite different meanings and usages. This is particularly the case in resource-poor contexts where material goods are scarce and this scarcity
can foster innovation.
More practical issues also had implications for ITN
use during pregnancy. In Kenya, occasionally, sleeping
arrangements together with the prioritization of children
sleeping under ITNs prevented pregnant women from
using the ITN that they received at ANC. In northern
Ghana, ITN use was seasonal, depending on the presence of mosquitoes and temperatures low enough to
sleep indoors. In Malawi, shortages of ITNs at health facilities limited the number of women who received free
ITNs and their use. However, when available, Malawian
women reported sleeping under ITNs.
As previous research has also highlighted [9,15,27],
knowledge of IPTp varies across different contexts. In
central Ghana and Kenya, pregnant women did not usually associate IPTp with malaria, whereas, in Malawi (as
has also been identified in previous research [28]) and
northern Ghana, it was more often linked to malaria,
but not always prevention. Reports of side effects linked
specifically to IPTp were therefore more prominent at
these sites and, in northern Ghana, vomiting was particularly associated with IPTp, and, therefore, seen as
one negative aspect of ANC. However, vomiting did not
lead directly to future non-compliance with IPTp or discourage ANC attendance: often, regardless of side effects
and without supervision women took their malaria prevention, Fansidar or white tablets because it was a
component of the ANC package, and in an effort to follow the instructions of healthcare staff see [11] for
more detail of ANC at the same sites. Similar confidence
in healthcare staffs instructions about IPTp has also
Page 10 of 13
been identified in The Gambia [27] and Uganda [29].

Even so, the women who did not adhere to IPTp and
there were suggestions that this occurred even if administered under DOT did so largely because of previous negative experiences. The instances of IPTp non-compliance
underscore a need for further in-depth (observational) research on compliance in real-world settings to ensure that
uptake of IPTp is not overestimated.
Optimal treatment of MiP was hindered by a lack of
available malaria diagnostic tests and by negative test results being ignored. Pregnant women, along with other
community members, generally viewed healthcare staff
as the authoritative source of malaria diagnosis, particularly severe malaria. Moreover, malaria tests were generally valued as a way of confirming the diagnosis. However,
even if available, the tests did not entirely dispel uncertainty
around the presence or absence of MiP. The non-specific
nature of its symptoms has prompted recent policy recommendations to test for malaria prior to administering
treatment [12]. Pregnancy however further complicates
the clinical diagnosis of malaria because there is overlap
between the symptoms of non-severe malaria and what
women often consider to be normal pregnancy experiences [10] or related illness [13]. Although a positive test
result resolved any uncertainty for healthcare staff and
pregnant clients, a negative result was not so conclusive:
in Ghana and Malawi, observations and womens reports
suggested that there instances of treatment in spite of a
negative result.
Ghanaian healthcare staff asserted that pregnant women
were exceptions to the policy of testing prior to treatment
and provided treatment based on symptoms even when a
malaria test result was negative. This is however a misinterpretation of the relevant policy document, which states
that, in the absence of laboratory diagnosis, pregnant
women with clinical symptoms of malaria should not be
denied anti-malarials because the risk of not treating far
outweighs the risks associated with overtreatment [21]. A
lack of confidence in malaria tests and reliance on symptoms
is however well-documented in other African contexts
[30,31]: for example, in northern Tanzania, overtreatment
of malaria in general was linked to a range of factors, including healthcare staff members assumptions about malaria being the most important disease and patients
expectations [30]. Overtreatment of MiP in Ghana was
linked to a (mis)interpretation of national policy, yet the
findings offer little insight into how this came about. However, the emphasis placed on MiP and its deleterious impact on the health of mother and child could have
contributed to the better-safe-than-sorry approach. The
reports of treatment in Malawi were however, more indirect. Healthcare staff only referred to treatment after a
positive result, even if such tests were not readily available.
Pregnant women who suspected malaria but received a

negative test result were disappointed when they did not

receive anti-malarials, but the data offer no insight into
whether this led healthcare staff to provide treatment.
With regard to malaria treatment, pregnant women
generally reported following the advice of healthcare
staff. However, although scattered, there were instances
of women ignoring such instructions or self-treating for
malaria without seeking diagnosis at a health facility. In
Ghana, where there were four cases of women who did
not complete their treatment course, side effects played
a role, as did confusion about the advice from healthcare
staff, particularly if it contradicted ideas about malaria
causation. In spite of such cases, health messages tended
to focus on the use of non-prescribed and non-biomedical
treatment during pregnancy and little emphasis was
placed on adherence to prescribed anti-malarial regimens.
The instances encountered in Kenya of women selftreating with drugs from other sources stood out from the
other sites. Yet, although similar findings have been made
at another Kenyan site [32], it is unclear to what extent
they were indicative of a more systematic trend of selfmedication. At all the sites, women made use of paracetamol and other cold remedies to combat the mild symptoms
associated with pregnancy and/or malaria. Such vague ideas
of malaria medication (presumably linked to the breadth
of the local illness that overlaps with malaria [10]), can contribute to inappropriate use of anti-malarials and other
malaria drugs through self-treatment or non-adherence
to prescribed treatment regimens.
A preference for anti-malarials that suit an individual
was more prominent in Malawi than at the other sites.
Such ideas about compatibility were perhaps the most
extreme examples regarding the role that personal experience plays in attitudes and behaviours towards MiP
interventions. Because pregnancy is generally considered
to be a particularly vulnerable bodily state and one in
which women experience a range of health complaints
[10], it is unsurprising that women display a preference
for health interventions that are viewed as not contributing further to the negative symptoms of pregnancy. Indeed, these experiences can albeit rarely override
womens typical adherence to the instructions that healthcare staff provide.
Strengths and limitations
The strengths of this study are intertwined with the anthropological approach: fieldwork over a one to two year
period enabled observations to be carried out to triangulate the data that respondents shared with the research
team and enabled women to be interviewed multiple
times over the course of their pregnancy to develop rapport, cross-check previous responses and to monitor
their experiences of care over the course of a pregnancy
with a follow-up post-delivery. However, the findings,
Page 11 of 13
with regard to malaria interventions, are limited by several

factors. Regarding ITN use, reported use could not be
confirmed with observational data at all the sites: as a result of the organization of dwellings and the restrictions
on researchers access to sleeping spaces, only in Kenya
was it regularly possible to observe the presence of ITNs
in womens sleeping quarters. Also, by relying on womens
reported malaria treatment practices because it was not
feasible to carry out direct observations of womens drug
intake outside of the health facility malaria selftreatment and non-compliance with anti-malarial treatment courses may have been underestimated across all
the sites. The lack of systematic observations of drug intake makes the cases of self-treatment and non-adherence
all the more striking and highlights a need for further
systematic analysis.
Conclusions
Respondents generally valued ITNs as malaria prevention, however, availability and cost were barriers to ITNs
ownership. Sleeping arrangements, climatic conditions
and prioritizing infants led to inconsistent ITN use during pregnancy. Health messages could address certain issues, for example, if ITNs are left unused during
pregnancy so that they are new items to mark the birth
of a child.
In contrast, awareness of IPTp varied notably across
the sites and, together with past experience of side effects, low awareness contributed, to non-adherence. Although IPTp was not always delivered under DOT,
adherence was common and this was linked to womens
overall attempts to follow the instructions of health staff
and their positive evaluation of ANC as a package of
interventions.
Malaria diagnostic tests were not always available, but
confirming a malaria diagnosis through a blood test was
generally valued. However, there were examples of overtreatment in Ghana and Malawi: in Ghana, this resulted
from misinterpretation of national policy, which illustrates the need for monitoring of local implementation.
Instance of self-treatment and non-compliance with prescribed treatment courses were linked to the broad local
illnesses that overlapped with malaria, the cost and availability of anti-malarials at health facilities and individual
preferences based on past and current experience of
the drugs. Health messages should therefore also address
adherence to prescribed anti-malarials as well as discouraging self-treatment.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
CP: contributed to the overall study design; supervised and assisted with
data collection in Kenya; analysed the data from this site; prepared the first
draft of the manuscript and contributed to its revision based on comments

from co-authors. AM: contributed to the overall study design; supervised and
assisted with data collection in Ghana and Malawi; analysed the data from
these sites;. provided comments on the first draft of the manuscript and
contributed to its revision based on the comments from co-authors. NAA:
collected data in central Ghana; revised the manuscript and provided comments.
LM: collected data at the Malawi site; revised the manuscript and provided
comments. SC: collected and supervised data collection in northern Ghana;
revised the manuscript and provided comments. FW: collected data in Kenya;
revised the manuscript and provided comments. AH: supervised data collection
in northern Ghana; revised the manuscript and provided comments. MJH:
supervised data collection in Kenya; revised the manuscript and provided
comments. LK: supervised data collection in Malawi; revised the manuscript and
provided comments. HT: supervised data collection in central Ghana; revised
the manuscript and provided comments. RP: conceived and designed study;
obtained project funding; provided comments and contributed to the revision
of the manuscript based on comments from all co-authors. All authors: read
and approved the final version of the manuscript.
Page 12 of 13
7.
8.
9.
10.
11.
12.
13.
Acknowledgements
The authors would like to thank the respondents who participated in the
programme of research at each site and took time to share their experiences
and opinions with members of the research team. We would also like to
express our gratitude to Lianne Straus who was instrumental in the early
phases of setting up the programme of research and to the large teams of
fieldworkers who participated in data collection in Ghana and Malawi:
Charity Siayire, Louis Alatinga, Dominic Anaseba, Gertrude Nyaaba and
Gideon Lugunia in northern Ghana; Collins Zamawe, Chikondi Kwalimba,
Alinafe Chibwana and Blessings N. Kaunda in Malawi. Our thanks also to
Peter Ouma who made a key contribution to setting up the study in Kenya,
and to Jayne Webster and Silke Lutzelschwab for the comments that they
provided on a previous version of the article.
The publication is supported and endorsed by the MiP Consortium, which is
funded through a grant from the Bill and Melinda Gates Foundation to the
Liverpool School of Tropical Medicine (www.gatesfoundation.org), Grant
OPP46099. The funders had no role in study design, data collection and
analysis, decision to publish, or preparation of the manuscript.
Author details
1
Centre for Social Science and Global Health, University of Amsterdam,
Amsterdam, The Netherlands. 2Centre de Recerca en Salut Internacional de
Barcelona (CRESIB, Hospital Clnic-Universitat de Barcelona), Barcelona, Spain.
3
Departamento de Antropologa Social, Universidad Complutense de Madrid,
Madrid, Spain. 4Department of Community Health, School of Medical
Sciences, Kwame Nkrumah University of Science and Technology, Kumasi,
Ghana. 5College of Medicine, University of Malawi, Blantyre, Malawi.
6
Navrongo Health Research Centre, Navrongo, Ghana. 7The Kenya Medical
Research Institute (KEMRI) and Centers for Disease Control and Prevention
(CDC) Research and Public Health Collaboration, Kisumu, Kenya. 8Research
and Development Division, Ghana Health Service, Accra, Ghana. 9Division of
Parasitic Diseases and Malaria, Centers for Disease Control and Prevention
(CDC), Atlanta, GA, USA.
Received: 5 September 2013 Accepted: 10 November 2013
Published: 20 November 2013
References
1. Menendez C, DAlessandro U, ter Kuile FO: Reducing the burden of malaria
in pregnancy by preventive strategies. Lancet Infect Dis 2007, 7:126135.
2. Guyatt HL, Snow RW: Impact of malaria during pregnancy on low birth
weight in sub-Saharan Africa. Clin Microbiol Rev 2004, 17:760769.
3. Desai M, ter Kuile FO, Nosten F, McGready R, Asamoa K, Brabin B, Newman
RD: Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis
2007, 7:93104.
4. Greenwood B, Alonso P, ter Kuile FO, Hill J, Steketee RW: Malaria in
pregnancy: priorities for research. Lancet Infect Dis 2007, 7:169174.
5. WHO: World Malaria Report 2012. Geneva: World Health Organization; 2012.
6. van Eijk AM, Hill J, Alegana VA, Kirui V, Gething PW, ter Kuile FO, Snow RW:
Coverage of malaria protection in pregnant women in sub-Saharan
Africa: a synthesis and analysis of national survey data. Lancet Infect Dis
2011, 11:190207.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Sevene E, Gonzlez R, Menndez C: Current knowledge and challenges of

antimalarial drugs for treatment and prevention in pregnancy. Expert
Opin Pharmacother 2010, 11:12771293.
Malaria in Pregnancy Consortium. [http://www.mip-consortium.org/]
Pell C, Straus L, Andrew EVW, Menaca A, Pool R: Social and cultural factors
affecting uptake of interventions for malaria in pregnancy in Africa: a
systematic review of the qualitative research. PLoS One 2011, 6:e22452.
Menaca A, Pell C, Manda L, Chatio S, Afrah NA, Were F, Hodgson A, Ouma P,
Kalilani L, Tagbor H, Pool R: Local illness concepts and their relevance for the
prevention and control of malaria during pregnancy in Ghana, Kenya and
Malawi: findings from a comparative qualitative study. Malar J 2013, 12:257.
Pell C, Meaca A, Were F, Afrah NA, Chatio S, Manda-Taylor L, Hamel MJ,
Hodgson A, Tagbor H, Kalilani L: Factors Affecting antenatal care attendance:
results from qualitative studies in Ghana, Kenya and Malawi. PLoS One 2013,
8:e53747.
Ghana Statistical Service: Guidelines for the treatment of malaria, 2010.
Geneva, Switzerland: World Health Organization; 2010:194.
Bardaj A, Sigauque B, Bruni L, Romagosa C, Sanz S, Mabunda S,
Mandomando I, Aponte J, Sevene E, Alonso PL: Clinical malaria in African
pregnant women. Malar J 2008, 7:27.
Ghana Statistical Service - Office of the President: Population and Housing
Census 2000. Accra, Ghana: Office of the President; 2002.
Smith L, Jones C, Adjei R, Antwi G, Afrah N, Greenwood B, Chandramohan
D, Tagbor H, Webster J: Intermittent screening and treatment versus
intermittent preventive treatment of malaria in pregnancy: user
acceptability. Malar J 2010, 9:18.
Ghana Statistical Service: Population and Housing Census 2000. Accra, Ghana:
Office of the President; 2008.
Oduro AR, Wak G, Azongo D, Debpuur C, Wontuo P, Kondayire F, Welaga P,
Bawah A, Nazzar A, Williams J: Profile of the navrongo health and
demographic surveillance system. Int J Epidemiol 2012, 41:968976.
Msyamboza K, Savage E, Kalanda G, Kazembe P, Gies S, DALESSANDRO U,
Brabin BJ: Trends in pregnancy outcomes in Malawian adolescents
receiving antimalarial and hematinic supplements. Acta Obstet Gynecol
Scand 2010, 89:10111016.
Adazu K, Lindblade KA, Rosen DH, Odhiambo F, Ofware P, Kwach J, Van Eijk AM,
Decock KM, Amornkul P, Karanja D: Health and demographic surveillance in
rural western Kenya: a platform for evaluating interventions to reduce
morbidity and mortality from infectious diseases. Am J Trop Med Hyg 2005,
73:11511158.
WHO: Policy Brief for the Implementation of Intermittent Preventive Treatment of
Malaria in Pregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP). [http://www.
who.int/malaria/publications/atoz/Policy_brief_IPTp-SP_implementation_
11april2013.pdf.pdf]
Ghana Health Service (GHS): Guidelines for Malaria in Pregnancy. [http://www.
ghanahealthservice.org/includes/upload/publications/GUIDELINES%20ON%
20MALARIA%5B1%5D.pdf]
Mbonye AK, Neema S, Magnussen P: Preventing malaria in pregnancy: a
study of perceptions and policy implications in Mukono district, Uganda.
Health Policy Plan 2006, 21:1726.
NetMark: NetMark formative qualitative research on insecticide treated
materials (ITMs) in Nigeria. Washington DC, USA: Academy for Educational
Development; 2001.
materials (ITMs) in Senegal. Washington DC, USA: Academy for Educational
Development; 2001.
materials (ITMs) in Uganda. Washington DC, USA: Academy for Educational
Development; 2001.
Chuma J, Okungu V, Ntwiga J, Molyneux C: Towards achieving Abuja targets:
identifying and addressing barriers to access and use of insecticides
treated nets among the poorest populations in Kenya. BMC Public Health
2010, 10:137.
Brabin L, Stokes E, Dumbaya I, Owens S: Gambian womens reliance on
health workers to deliver sulphadoxine-pyrimethamine as recommended
intermittent preventive treatment for malaria in pregnancy. Malar J 2009,
8:25.
Launiala A, Honkasalo ML: Ethnographic study of factors influencing
compliance to intermittent preventive treatment of malaria during
pregnancy among Yao women in rural Malawi. Trans R Soc Trop Med Hyg
2007, 101:980989.

Page 13 of 13
29. Mbonye AK, Bygbjerg I, Magnussen P: Intermittent preventive treatment

of malaria in pregnancy: evaluation of a new delivery approach and the
policy implications for malaria control in Uganda. Health Policy 2007,
81:228241.
30. Chandler CI, Jones C, Boniface G, Juma K, Reyburn H, Whitty CJ: Guidelines
and mindlines: why do clinical staff over-diagnose malaria in Tanzania?
A qualitative study. Malar J 2008, 7:53.
31. Chandler CI, Mangham L, Njei AN, Achonduh O, Mbacham WF, Wiseman V:
As a clinician, you are not managing lab results, you are managing the
patient: How the enactment of malaria at health facilities in Cameroon
compares with new WHO guidelines for the use of malaria tests. Soc Sci
Med 2012, 74:15281535.
32. Soud FA: Medical pluralism and utilization of maternity health care services by
Muslim women in Mombasa, Kenya. University of Florida: PhD Thesis; 2005.
doi:10.1186/1475-2875-12-427
Cite this article as: Pell et al.: Prevention and management of malaria
during pregnancy: findings from a comparative qualitative study in
Ghana, Kenya and Malawi. Malaria Journal 2013 12:427.
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Pencegahan dan pengelolaan malaria selama kehamilan: Temuan

dari perbandingan studi kualitatif di Ghana, Kenya dan Malawi
Christopher Pell1,2*, Arantza Meaca2,3, Nana A Afrah4, Lucinda Manda-Taylor5, Samuel Chatio6,
Florence Were7, Abraham Hodgson8, Mary J Hamel9, Linda Kalilani5, Harry Tagbor4 and Robert
Pool1,2
Abstrak
Latar Belakang: Di daerah endemik sub-Sahara Afrika, malaria selama kehamilan (MIP)
adalah dicegah utama penyebab kesakitan dan kematian ibu dan bayi. Direkomendasikan
pencegahan dan pengendalian MIP saat ini termasuk pengobatan intermiten pencegahan
(IPTp), distribusi insektisida kelambu (ITN) dan kasus yang tepat pengelolaan. Artikel ini
membahas konteks sosial dan budaya untuk penyerapan intervensi ini di empat lokasi di
seluruh Afrika.
Metode: Sebuah studi kualitatif komparatif dilakukan di empat lokasi di tiga negara: Ghana,
Malawi dan Kenya. Wawancara individu dan kelompok dilakukan dengan wanita hamil,
keluarga mereka, pemimpin opini, lainnya anggota masyarakat dan penyedia layanan
kesehatan. Pengamatan, yang berfokus pada perilaku yang terkait dengan pencegahan MIP
dan pengobatan, juga dilakukan di fasilitas kesehatan dan masyarakat setempat.
Hasil: ITN umumnya diakui sebagai penting untuk pencegahan malaria. Namun,
ketersediaan dan penggunaan berbeda di seluruh situs. Di Malawi dan Kenya, ITN yang
dicari item, tapi ada keluhan tentang memanfaatkankemampuan. Di tengah Ghana, wanita
diselamatkan ITN sampai kelahiran anak dan mereka digunakan musiman di utara Ghana. Di
Kenya dan tengah Ghana, wanita hamil tidak mengasosiasikan IPTp dengan malaria,
sedangkan, di Malawi dan utara Ghana, IPTp dikaitkan dengan malaria, tetapi tidak selalu
dengan pencegahan. Meskipun IPTp kepatuhan adalah umum di semua situs, apakah
disampaikan dengan pengobatan diamati secara langsung atau tidak, beberapa wanita tidak
mematuhi IPTp sering mengutip efek samping sebelumnya. Meskipun umumnya dipandang
sebagai positif, pengalaman pengujian malaria bervariasi di seluruh empat lokasi: pengobatan
kadang-kadang diberikan meskipun diagnosis negatif di Ghana (diamati) dan Malawi
(dilaporkan). Meskipun umumnya mengikuti saran dari staf kesehatan, terutama di Kenya,
pengalaman pribadi, dan ketersediaan dan aksesibilitas obat - termasuk anti-malaria dipengaruhi pengobatan MIP.
Kesimpulan: Meskipun ITN yang dinilai sebagai pencegahan malaria, pesan kesehatan bisa
mengatasi masalah yang mengurangi penggunaannya selama kehamilan dalam konteks
tertentu. Dampak dari efek samping sebelumnya pada kepatuhan terhadap IPTp dan rejimen
pengobatan anti malaria selama kehamilan juga memerlukan perhatian. Overtreatment dari
MIP menyoroti perlu memantau pelaksanaan pedoman manajemen kasus MIP.
Kata kunci: Malaria, Kehamilan, IPTp, insektisida kelambu, manajemen kasus ITN, Malaria
Latar belakang
Di daerah endemik sub-Sahara Afrika,
malaria selama kehamilan (MIP) merupakan
penyebab utama dari ibu dapat dicegah dan
morbiditas dan kematian bayi [1]. Malaria
selama
senyawa
kehamilan
atau
memprovokasi anemia, yang, ketika parah,
meningkatkan
risiko
kematian
ibu
(diperkirakan sekitar 10.000 kematian setiap
tahunnya [2]). Berat badan lahir rendah
(terkait dengan sekitar 100.000 kematian
bayi tahunan di Afrika [2]), persalinan
prematur, infeksi kongenital dan reproductkerugian
ive
juga
terkait
dengan
MIP [3]. Meskipun demikian, terlepas dari
terkait beban tinggi morbiditas dan
mortalitas, MIP adalah, sampai saat ini,
diakui
sebagai
daerah
terabaikan
penelitian [4].
Direkomendasikan
pencegahan
dan
pengendalian MIP saat strategi di bidang
stabil moderat untuk trans- malaria tinggi
Misi meliputi administrasi pat dicegah
intermitenive pengobatan (IPTp) dengan
sulphadoxine-pyrimethamine (SP), distribusi
insektisida kelambu (ITN) dan manajemen
kasus yang tepat [5]. Meskipun progress
dibuat dalam dekade terakhir, cakupan IPTp
dan ITN antara perempuan Afrika hamil
tetap
inad
menyamakan [6]. Untuk
manajemen kasus yang tepat, paling tepat
pengobatan priate tergantung pada spesies
malaria, keparahan infeksi, pola lokal
resistensi
obat,
obat
memanfaatkan
kemampuan dan usia kehamilan [7]. Ini,
dikombinasikan dengan incomplete MIP data
surveilans
di
sub-Sahara
Afrika [5],
mempersulit perkiraan manajemen kasus
yang tepat. Namun demikian, mengingat
ketersediaan tidak cukup diagnostic tes dan
terapi kombinasi berbasis artemisinin (ACT)
[5] (direkomendasikan sebagai pengobatan
lini pertama untuk MIP selama kedua dan
ketiga
trimester),
manajemen
kasus
kemungkinan menjadi sub-optimal.
Dalam menanggapi tantangan pencegahan
MIP dan control, sebuah konsorsium riset
dari 47 lembaga mitra di 32 negara, didirikan
dan saat ini conducting berbagai kegiatan
ilmiah di Afrika, Asia, Australasia (Papua
Nugini) dan Amerika Selatan [8]. MIP

Konsorsium mengambil ap multi-disiplin
proach
untuk
MIP,
menyatukan
immunologists,
epidemiologists,
ahli
kesehatan masyarakat dan ilmuwan sosial.
Tulisan ini mengacu pada hasil dari
antropologi Program penelitian yang
merupakan bagian dari consor- yang
Kesehatan Masyarakat Kelompok Dampak
tium ini.
Tujuan keseluruhan dari mobil-penelitian
antropologi Ried di bawah naungan
Konsorsium MIP adalah untuk berkontribusi
pada pengembangan dan implementasi MIP
intervensi yang tepat dengan mendapatkan
yang mendalam pemahaman konteks sosial
dan budaya dari MIP. Sebuah tinjauan
penelitian yang dilakukan sebelumnya
diidentifikasi empat topik yang luas yang
mempengaruhi penyerapan MIP antar
konvensi- [9]: konsep malaria dan risiko
dalam kehamilan, sikap terhadap pencegahan
dan pengobatan malaria; per-ceptions dari
(ANC) layanan perawatan antenatal; dan
structural faktor. Keempat tema telah banyak
dieksplorasi oleh Antropologi Tim MIP
Consortium. artikel ini berfokus pada sikap
terhadap pencegahan MIP dan mandate
pengelolaan (pengujian dan pengobatan); dua
artikel terpisah fokus pada sikap terhadap
konsep malaria dan risiko selama
kehamilan [10] dan persepsi dari ANC [11].
Analisis
faktor
struktural
yang
mempengaruhi MIP pra pencegahan dan
kontrol integral semua tiga artikel.
Dalam beberapa tahun terakhir, penelitian
malaria dan kebijakan syarakatnity telah
semakin menegaskan diagnosis yang akurat
untuk enyakin perawatan yang tepat
malaria. Dengan tidak adanya tes diagnostik,
malaria umumnya lebih didiagnosis menjadi
penyebab gejala non-spesifik: sakit kepala,
kelelahan, ab nyeri dominal, otot dan / atau
sendi sakit, demam, menggigil, keringat,
muntah dan malaise [1 2]. Oleh karena itu,
sebagai seorang result kekhawatiran tentang
terlalu sering menggunakan obat malaria,
2010 Pedoman WHO untuk pengobatan
malaria-rekomendasi diagnosis diperbaiki
dengan mikroskop atau tes diagnostik cepat
(RDT) untuk semua orang yang menderita

malaria
diduga
sebelum
perawatan [12]. Selain itu, ada tumpang
tindih menjadi tween malaria dan keluhan
kesehatan lainnya perempuan during
kehamilan. Dengan demikian konfirmasi
diagnostik MIP adalah sangat penting untuk
manajemen yang tepat [13] dan merupakan
isu kunci untuk artikel ini.
Untuk memberikan wawasan ke dalam
konteks sosial dan budaya untuk penyerapan
intervensi untuk pencegahan malaria dan
kontrol, artikel ini membahas penelitian
berikut pertanyaan: apa sikap dan perilaku
terhadap Pencegahan MIP dan manajemen
antara hamil perempuan, staf kesehatan dan
anggota masyarakat lainnya di empat lokasi
di Ghana (utara dan tengah), Kenya (Nyanza
Propinsi)
dan
Malawi
(wilayah
selatan); bagaimana tidak konteks sosial dan
budaya mempengaruhi atti- ini tudes dan
perilaku; dan apa implikasi dari sikap dan
perilaku untuk desain yang efektif MIP
intervensi? Untuk mengidentifikasi dan
memeriksa isu-yang relevan Gugat yang
mungkin akan diambil untuk diberikan, comsebuah Pendekatan parative diambil dan data
disajikan dari empat lokasi.
Metode
Hasil yang disajikan dalam artikel ini
diambil dari Studi banding dilakukan di
empat lokasi di tiga negara. Penelitian ini
dilakukan oleh tim dari repencari yang
anggotanya berdasarkan seluruh situs dan di
Barcelona (Spanyol).
Pengaturan
Studi ini dimasukkan satu negara dari
masing-masing tiga wilayah utama SubSahara Afrika: Ghana di West Afrika, Kenya
di Afrika Timur dan Malawi di Southern
Afrika. Dua situs dengan kekhususan
regional yang penting dipilih di Ghana
karena
beberapa
alasan:
untuk
mengumpulkan Data dalam setidaknya satu
situs dari masing-masing MIP Konsorsium
pengobatan dan pencegahan kegiatan
utama; untuk menyertakan daerah dengan
pola yang berbeda penularan malaria; dan
untuk memeriksa intra serta variasi antarnegara.

Di tengah Ghana, kerja lapangan
dilakukan di dua districts dari Ashanti
Region: Ejisu Juaben dan Ahafo Ano
Selatan. Di kedua kabupaten, pertanian
adalah pro utama ductive aktivitas dan ada
proporsi yang signifikan dari migran internal
selain mayoritas etnis kelompok, Asante
[1 4]. Di situs ini, penularan malaria cukup
tinggi dan terjadi sepanjang tahun dengan
puncak
selama
hujan
Mei-Oktober
[1 5]. Dalam setiap district, pengumpulan
data dilakukan di kabupaten sakit seperti
pitals, 2-3 Puskesmas dan beberapa yang
lebih kecil klinik.
Di Ghana utara, Upper East Region, kerja
lapangan situs yang terletak di KassenaNankana District. Ini daerah adalah bagian
dari Sahel dan pengalaman hanya satu
tahunan musim hujan di mana orang tumbuh
millet,
jagung
dan
sayuran
untuk
subsisten. Selama sisa tahun, sebagian
penduduk bermigrasi ke daerah lain. The
Kassena dan Nankani, membuat hampir 90%
dari populasi distrik [16]. Di sini, malaria
transmisinya adalah abadi tetapi ada pola
musiman dengan puncak transmisi yang
bertepatan dengan hujan besar (Mei sampai
Oktober) dan rendahnya tingkat infeksi
selama
musim
kemarau [17]. Data
dikumpulkan di kabupaten sakit seperti pital
di Navrongo, (ibukota), dan penjangkauan
komunitas layanan berbasis, yang umum di
seluruh daerah.
Lapangan juga terjadi di Chikwawa dan
Blantyre Kabupaten, di wilayah selatan
Malawi. Utama kelompok etnis di Blantyre
District adalah Chewa dan Yao, sedangkan
di Chikwawa mereka Manganja dan
Sena. Paling perempuan di daerah menanam
tanaman untuk subsisten dan dijual di
pasar. Kedua kabupaten berada di daerah
tinggi penularan malaria abadi [18].
Lapangan berlangsung di tiga rumah sakit,
dan enam pusat kesehatan yang menyediakan
Layanan ANC untuk para wanita di daerahdaerah.
Akhirnya, di Kenya, kerja lapangan
dilakukan di Siaya District (Nyanza
Propinsi) di mana pokok etnis kelompok,

Luo, membuat lebih dari 95% dari populasi.
Kegiatan mata pencaharian termasuk
pertanian subsisten jagung, sorgum, millet
dan singkong. Sebagai akibat dari relative
kesempatan kerja yang terbatas, migrasi ke
perkotaan pusat adalah umum, terutama ke
Kisumu, terdekat kota. Penularan malaria
tinggi dan abadi [19] dengan beban penyakit
terbesar ditanggung oleh anak-anak dan
kehamilan
yang
wanita
nant. Data
dikumpulkan di rumah sakit kabupaten dan
fasilitas kesehatan yang lebih kecil di mana
ANC disampaikan.
Pada masing-masing situs, berbagai klinis
dan non-klinis Studi MIP intervensi
pencegahan
dan
pengendalian
telah
dilakukan. Beberapa studi ini tumpang tindih
dengan pengumpulan data untuk penelitian
ini. Oleh karena itu, selama pengumpulan
data dan analisis, upaya dilakukan untuk
mengecualikan pengalaman pencegahan dan
pengendalian MIP dalam klinis atau
penelitian non-klinis. Selanjutnya, seluruh
ini Artikel, karena alasan singkatnya, situs
yang disebut sebagai "Kenya", "Malawi",
"pusat Ghana" dan "Ghana utara". Singkatan
ini tidak Namun diartikan sebagai setiap
upaya generalisasi regional atau nasional.
Pengumpulan data
Pendekatan
antropologis
dibawa
ke
pengumpulan data. Ini mensyaratkan periode
tahun panjang (atau lebih) dari lapangan di
setiap situs, berbagai kegiatan pengumpulan
data, termasuk narasi dan observasional, dan
fleksibel, refleksif dan proses berulang
desain alat, pengumpulan data, dan
analisa. Penggunaan
beberapa
alat
pengumpulan data dengan responden
heterogen memastikan bahwa temuan ini
dapat menjadi Triangulasi dan kehandalan
mereka diuji. Untuk mengurangi pos- yang
Pengaruh jawab bias individu pada temuan
studi, di setiap situs, beberapa peneliti
mengumpulkan data.
Penelitian lapangan dilakukan antara
April 2009 dan Agustus 2011, dan
berlangsung dari satu tahun di Malawi untuk
lebih
dari
dua
tahun
di
tengah
Ghana. Dibantu oleh dua Barcelona peneliti

berdasarkan (AM dan CP), petugas lapangan
menghabiskan mantan periode cenderung
waktu di pemukiman dimana data yang
dikumpulkan dan dicatat pengalaman mereka
dari peserta diamati konservasi di buku
harian bidang. Pada tahap pertama, di setiap
lokasi, menggunakan bebas daftar dan
menyortir latihan, tim peneliti menjelajahi
masalah utama yang wanita hamil
pengalamanence. Kemudian, wawancara dan
diskusi kelompok yang conmenyalurkan,
beberapa wanita (studi kasus) diikuti dan
mewawancarai beberapa kali selama
kehamilan yang mereka nancies, dan
pengamatan dilakukan di syarakat yang
nities
dan
di
fasilitas
kesehatan
setempat. Bahasa yang digunakan untuk
berinteraksi dengan informan tergantung
pada preferensi mereka (Bahasa Inggris dan
bahasa lokal yang berbeda). Mendalam antar
pandangan dan kelompok diskusi dicatat,
ditranskrip dan diterjemahkan ke dalam
bahasa Inggris.
Wawancara mendalam cenderung untuk
memulai dengan ulang luas pertanyaan kunci
yang berhubungan dengan kehamilan dan
berakhir dengan pertanyaan tentang malaria
dalam kehamilan dan pengalaman dengan
pencegahan dan pengendalian malaria.
Sebaliknya, kelompok diskusi sering dimulai
dengan
pertanyaan-pertanyaan
umum
tentang malaria, fokus nanti kelompok rentan
malaria
dan
menyelesaikan
dengan
pencegahan malaria dan kontrol. Tema
lainnya, terkait dengan MIP, seperti
miscarriage, lahir mati, pengiriman prematur,
berat lahir dan anemia dan penyebabnya juga
dieksplorasi selama pekerjaan lapangan.
Pengumpulan data dan analisis dilakukan di
paralel memungkinkan penggabungan tema
yang muncul di desain alat, dan redefinisi
pertanyaan 'dan attuning.
Anggota tim peneliti yang berbasis di
Barcelona membuat kunjungan triwulan ke
lokasi penelitian. Selama kunjungan tersebut,
proses pembekalan dan refleksi berlangsung
dengan pekerja lapangan. Para peneliti yang
berbasis di Barcelona itu juga dapat
berpartisipasi dalam pengumpulan data, dan

menyediakan berkelanjutan latihan.
Responden
Lima
kategori
utama
responden
diwawancarai ibu hamil, keluarga mereka,
komunitas anggota, pemimpin opini dan
penyedia layanan kesehatan. Pursampel posif
digunakan untuk memastikan interaksi
dengan berbagai pengalaman. Menikah dan
belum menikah wanita hamil dari berbagai
usia, paritas dan gestasi usia nasional dari
seluruh pemukiman yang berbeda (dalam
situs
lapangan)
diwawancarai. Kerabat
termasuk terutama ibu, ibu mertua dan suami
dari wanita hamil. Sampel pemimpin opini
adalah terdiri dari berbagai tokoh agama,
adat dan otoritas politik, dan perempuan
yang relevan di local masyarakat. Akhirnya,
staf ANC, apoteker dan obat penjual, dukun
bayi (dukun beranak), dan lainnya
penyembuh (yang hadir untuk wanita hamil
atau ditangani malaria) diwawancarai di
setiap situs. Responden diidentifikasi di
klinik ANC dan melalui kontak di local
masyarakat, yang dikembangkan sebagai
lapangan melanjutkan. Jumlah akhir peserta
adalah hasil dari di- yang sampel rected dan
titik jenuh, dimana tidak adawawasan baru
lanjut diidentifikasi dari wawancara.
Analisis data
Di setiap situs, tahap pertama analisis data
berlari secara parallel untuk pengumpulan
data. Menggunakan ATLAS.ti 6, buku kode
fleksibel dikembangkan dan direvisi
menggunakan kombinasi kategori didirikan
berdasarkan penelitian asli pertanyaan dan
tema yang muncul dari data. ParPerhatian
TERTENTU dibayar ketika menganalisis
wawancara dengan studi kasus untuk
mengidentifikasi perubahan rewanita sponses
selama kehamilannya, misalnya, berkaitan
dengan ITN digunakan. Hasil awal yang
diperoleh dari analisis spesifik lokasi ini
dibandingkan dan dismengumpat di antara
anggota tim di periodic pertemuan seluruh
pengumpulan data. Dalam tahap kedua, data
yang terkait dengan kode relevan dengan
malaria di kehamilan yang persepsi nancy,
diekstraksi, disusun dan dibahas antara

penulis satu dan dua, melihat kesamaan,
perbedaan dan variasi antara dan di dalam
berbagai situs.
Pernyataan Etika
Secara keseluruhan etika izin diperoleh dari
Klinik Penelitian Komite Etika, Rumah Sakit
Klinik-Universitas dari Barcelona. Pisahkan
etika lokal izin adalah obtained di setiap
situs: di Ghana, izin diperoleh dari
Institutional Review Board dari Navrongo
Pusat Kesehatan Penelitian, Navrongo dan
Komite Etika Penelitian Manusia, Kwame
Nkrumah Universitas Sains & Teknologi,
Kumasi; di Kenya, clearance diperoleh dari
Badan
Lembaga
Ulasan-pusatters
Pengendalian dan Pencegahan Penyakit di
Atlanta dan dari National Komite Etik
Review, Kenya Medical Research Institute,
Nairobi; dan di Malawi, izin diperoleh dari
College of Medicine Penelitian dan Komite
Etika. Yang disetujui oleh semua etika
komite peninjau dan review kelembagaan
papan, informed consent diperoleh secara
lisan dari penelitian peserta. Oral informed
consent bukan ditulis diperoleh karena
prosedur penelitian yang diajukan min risiko
Imal untuk belajar peserta dan untuk
menghindari kemungkinan pengaruh negatif
dari persetujuan tertulis dari hubungan
menjadi
peneliti
tween
dan
responden. Dengan kesepakatan peserta,
persetujuan verbal rekaman suara sebelum
untuk setiap wawancara atau fokus diskusi
kelompok.
Diskusi
Di semua situs, responden mengakui bahwa
tidur di bawah ITN adalah cara mencegah
malaria. Bahkan meskipun responden di
semua situs yang ditawarkan penjelasan yang
tambahan negara (seperti kebersihan yang
buruk) untuk serangan malaria (atau penyakit
lokal yang tumpang tindih dengan
debiomedis malaria didenda (lihat [10] untuk
informasi lebih lanjut), nyamuk dilaporkan
menjadi penyebab utama. Koneksi bahwa
responden dibuat antara ITN menggunakan
dan
malaria
pencegahan
karenanya
mengejutkan. Malaria
juga
dipandang
sebagai penyakit yang umum bagi wanita
hamil, dan dianggap sebagai penyebab
(bersama dengan berkontribusi lainnya
faktor) keguguran [10].
Selain itu, sikap negatif terhadap ITN
jarang dan tidak ada keberatan khusus untuk
penggunaan mereka selama kehamilan.
Temuan ini, dalam bervariasi sosial dan
budaya konteks dengan mekanisme yang
berbeda dari distribusi ITN, kontras dengan
beberapa studi sebelumnya yang memiliki
tinggi masalah kesehatan terang terkait
dengan ITN menggunakan selama kehamilan
yang nancy, terutama yang berkaitan dengan
dampak dari perawatan insektisida pada anak
yang belum lahir [2 2- 25]. Studi ini
dilakukan sebelum distribusi ITN dari tahan
lama dan itu sering insektisida, dan Proses
pengobatan
ulang,
yang
memicu
kekhawatiran tersebut. Satu studi multi-situs
di Kenya menyoroti tambahan sikap negatif
terhadap ITN termasuk keluhan tentang
kampanye distribusi menargetkan wanita
hamil dan bayi [26]. Komentar seperti itu
dikaitkan dengan kurangnya a informasi
yang
menghubungkan
peningkatan
kerentanan
malaria
dengan
ITN
distribusi [26]. Sebaliknya, responden dalam
hal ini Studi sering disorot peningkatan
risiko wanita hamil malaria [1 0] dan tidak
ada komentar negatif seperti tentang
menargetkan ibu hamil yang ditemui.
Makna yang lebih luas terkait dengan ITN
memiliki varying implikasi untuk mereka
gunakan. Di tengah Ghana, wanita dilihat
ITN sebagai konsumen yang baik dan karena
itu meninggalkan mereka tidak terpakai
selama kehamilan, tergantung mereka untuk
pertama waktu untuk menandai kelahiran
anak. Responden Kenya juga dihargai ITN
sebagai barang rumah tangga dengan
menggunakan beberapa, seperti melindungi
tanaman dari burung. Namun, dalam hal ini
konteks, penggunaan beberapa dari ITN
tidak tentu mencegah wanita hamil dari tidur
di bawah mereka. Temuan ini adalah
pengingat tentang bagaimana-teknologi
kesehatan gies (dalam hal ini, dimaksudkan
oleh desainer untuk malaria pencegahan)
dapat mengambil makna yang sangat

berbeda dan kita- usia. Hal ini terutama
terjadi di miskin sumber daya conteks di
mana barang-barang material yang langka
dan kelangkaan ini dapat mendorong inovasi.
Masalah yang lebih praktis juga memiliki
implikasi untuk ITN digunakan selama
kehamilan. Di Kenya, kadang-kadang, tidur
pengaturan bersama dengan prioritas anakanak tidur di bawah ITN dicegah wanita
hamil dari menggunakan ITN yang mereka
terima di ANC. Di bagian utara Ghana, ITN
penggunaan adalah musiman, tergantung
pada tekanan yang ence nyamuk dan suhu
rendah cukup untuk tidur di dalam
ruangan. Di Malawi, kekurangan ITN di
kesehatan FA cilities membatasi jumlah
perempuan yang menerima gratis ITN dan
penggunaannya. Namun,
bila
tersedia,
Malawi wanita dilaporkan tidur di bawah
ITN.
Seperti penelitian sebelumnya juga telah
menyoroti [9, 15,27], pengetahuan IPTp
bervariasi di seluruh konteks yang
berbeda. Di pusat Ghana dan Kenya, ibu
hamil tidak biasanya kategorinya sekutu
mengasosiasikan IPTp dengan malaria,
sedangkan, di Malawi (sebagai juga telah
diidentifikasi dalam penelitian sebelumnya
[28]) dan utara Ghana, itu lebih sering
dikaitkan dengan malaria, tetapi tidak selalu
pencegahan. Laporan efek samping terkait
khusus untuk IPTp karenanya lebih menonjol
di situs tersebut dan, di Ghana utara, muntahpartai itu khusus- terkait dengan IPTp, dan,
oleh karena itu, dipandang sebagai salah satu
aspek negatif dari ANC. Namun, muntah
tidak mengarah langsung ke depan
ketidakpatuhan dengan IPTp atau dis
keberanian ANC kehadiran: sering, terlepas
dari efek samping dan tanpa pengawasan
wanita mengambil pra malaria mereka vensi,
"Fansidar" atau "tablet putih" karena itu
adalah komponen dari paket ANC, dan
dalam upaya untuk folrendah petunjuk dari
staf kesehatan - lihat [11] untuk lebih detail
dari ANC di situs yang sama. Keyakinan
yang sama dalam perawatan kesehatan
instruksi staf tentang IPTp memiliki juga
telah diidentifikasi di Gambia [27] dan
Uganda [29]. Meski begitu, para wanita yang

tidak mematuhi IPTp dan ada saran bahwa
ini terjadi bahkan jika administratiftered
bawah DOT - melakukannya terutama
karena negatif yang sebelumnya pengalaman
tive. Contoh dari IPTp ketidakpatuhan
menggarisbawahi kebutuhan untuk lebih
mendalam (pengamatan) kembali pencarian
di kepatuhan dalam pengaturan dunia nyata
untuk memastikan bahwa penyerapan IPTp
tidak berlebihan.
Pengobatan yang optimal dari MIP
terhalang oleh kurangnya tersedia malaria tes
diagnostik dan uji ulang negative Hasil
pengujian diabaikan. Wanita hamil, bersama
dengan lainnya anggota masyarakat,
umumnya dipandang staf kesehatan sebagai
sumber
otoritatif
diagnosis
malaria,
khususnya
untuk
paralarly
malaria
berat. Selain itu, tes malaria yang
genersekutu dihargai sebagai cara untuk
mengkonfirmasi diagnosis. Namun, bahkan
jika tersedia, tes tidak sepenuhnya
menghilangkan
ketidakpastian
sekitar
tidaknya MIP. Non-spesifik sifat gejala telah
mendorong
kebijakan
baru
mendasi
rekomendasi-untuk menguji malaria sebelum
pemberian
pengobatan [12]. Kehamilan
merumitkan namun lanjut diagnosis klinis
malaria karena ada tumpang tindih antara
gejala malaria non-berat dan apa perempuan
sering
anggap
kehamilan
normal
pengalamanences [10] atau penyakit yang
berhubungan [13]. Meskipun tes positif Hasil
diselesaikan ketidakpastian bagi staf
kesehatan dan klien hamil, hasil negatif tidak
begitu meyakinkan: di Ghana dan Malawi,
pengamatan dan laporan perempuan
menyarankan bahwa ada kasus pengobatan
terlepas dari hasil negatif.
Staf kesehatan Ghana menegaskan bahwa
wanita hamil adalah pengecualian untuk
kebijakan pengujian sebelum perawatan dan
perawatan yang diberikan berdasarkan gejala
bahkan
ketika
hasil
tes
malaria
negatif. Namun ini adalah sebuah misinterpretation dari dokumen kebijakan yang
relevan, yang menyatakan bahwa, dengan
tidak adanya diagnosis laboratorium, hamil
wanita dengan gejala klinis malaria tidak
boleh membantah anti-malaria karena risiko

tidak memperlakukan jauh melebihi risiko
yang
terkait
dengan
overtreatment
[21]. SEBUAH kurangnya kepercayaan
dalam tes malaria dan ketergantungan pada
gejala adalah Namun terdokumentasi dengan
baik dalam konteks Afrika lainnya [30, 31]:
misalnya, di Tanzania utara, overtreatment
malaria pada umumnya dikaitkan dengan
berbagai faktor, diasumsi daerah, termasuk
anggota staf kesehatan 'tentang malfungsi
aria menjadi penyakit dan pasien yang paling
penting ' harapan [3 0]. Overtreatment dari
MIP di Ghana adalah terkait dengan (mis)
interpretasi kebijakan nasional, namun
Temuan menawarkan sedikit wawasan
tentang bagaimana ini terjadi. Bagaimana
pernah, penekanannya ditempatkan pada
MIP dan im- merusak nya pakta pada
kesehatan ibu dan anak bisa memiliki
berkontribusi pada pendekatan yang lebih
baik-aman-dari-maaf. Itu laporan pengobatan
di Malawi yang bagaimanapun, lebih indir
dll. Staf kesehatan hanya disebut pengobatan
setelah hasil positif, bahkan jika tes tersebut
tidak tersedia.Ibu hamil yang diduga malaria
tetapi menerima Hasil tes negatif kecewa
ketika mereka tidak menerima anti-malaria,
tetapi data tidak menawarkan wawasan
apakah ini menyebabkan staf kesehatan
untuk memberikan pengobatan.
Berkenaan dengan pengobatan malaria,
ibu hamil umumnya melaporkan mengikuti
saran kesehatan staf. Namun, meskipun
tersebar, ada kasus perempuan mengabaikan
instruksi atau self-mengobati untuk seperti
malaria tanpa mencari diagnosis di fasilitas
kesehatan. Di Ghana, di mana ada empat
kasus perempuan yang melakukan tidak
menyelesaikan kursus pengobatan mereka,
efek samping dimainkan peran, seperti yang
dilakukan kebingungan tentang saran dari
kesehatan Staf, terutama jika bertentangan
ide tentang malaria hal menyebabkan.
Meskipun kasus tersebut, pesan kesehatan
cenderung untuk fokus pada penggunaan
non-resep dan non-biomedis pengobatan
selama kehamilan dan sedikit penekanan
adalah ditempatkan pada kepatuhan terhadap
diresepkan rejimen anti-malaria. Contoh
ditemui di Kenya perempuan diri mengobati

dengan obat dari sumber lain berdiri keluar
dari situs lain. Namun, meskipun temuan
serupa telah dilakukan di situs lain Kenya
[3 2], tidak jelas sampai sejauh mana mereka
menunjukkan tren yang lebih sistematis diri
obat. Di
semua
situs,
perempuan
memanfaatkan paracetamol dan obat dingin
lainnya untuk memerangi gejala ringan
terkait dengan kehamilan dan / atau
malaria. Ide yang tidak jelas seperti dari
"malaria" obat (mungkin terkait dengan
lebarnya dari penyakit lokal yang tumpang
tindih dengan malaria [10]), dapat
penghargaan untuk penggunaan yang tidak
anti-malaria dan lainnya "Obat malaria"
melalui self-pengobatan atau non-kepatuhan
untuk rejimen pengobatan yang diresepkan.
Sebuah preferensi untuk anti-malaria yang
"sesuai" seorang individu lebih menonjol di
Malawi daripada di situs lain. Ide-ide
tersebut tentang kompatibilitas yang
mungkin yang paling contoh ekstrim
mengenai peran yang mantan pribadi
perience memainkan sikap dan perilaku
terhadap MIP intervensi. Karena kehamilan
umumnya dianggap menjadi negara tubuh
sangat rentan dan satu di yang perempuan
mengalami berbagai keluhan kesehatan
[10], tidak mengherankan bahwa wanita
menampilkan preferensi untuk intervensi
kesehatan yang dipandang sebagai tidak
contributing lanjut dengan gejala negatif
kehamilan. Diperbuatan, pengalaman ini bias
meskipun jarang override kepatuhan khas
perempuan dengan petunjuk yang dengan
kesehatan staf perawatan memberikan.
Kekuatan dan keterbatasan
Kekuatan dari penelitian ini terkait dengan
an- yang Pendekatan thropological: lapangan
selama 1-2 tahun periode diaktifkan
pengamatan
harus
dilakukan
untuk
trianguakhir data bahwa responden bersama
dengan penelitian Tim dan memungkinkan
perempuan untuk diwawancarai beberapa
kali selama kehamilan mereka untuk
mengembangkan RAP pelabuhan, crosscheck tanggapan sebelumnya dan untuk
memantau pengalaman mereka perawatan
selama kehamilan dengan pasca-melahirkan

tindak lanjut. Namun, temuan, berkenaan
dengan intervensi malaria, dibatasi oleh
beberapa faktor. Mengenai ITN digunakan,
melaporkan
penggunaan
tidak
bias
dikonfirmasi dengan data pengamatan di
semua situs: sebagai result dari organisasi
tempat tinggal dan pembatasan akses peneliti
untuk ruang tidur, hanya di Kenya adalah
secara teratur mungkin untuk mengamati
kehadiran
ITN
di
tempat
tidur
perempuan. Juga, dengan mengandalkan
perempuan melaporkan praktik pengobatan
malaria - karena itu tidak layak untuk
melaksanakan pengamatan langsung dari
obat perempuan asupan luar fasilitas
kesehatan - diri malaria pengobatan dan nonkepatuhan dengan memperlakukan antimalaria Kursus ment mungkin telah
diremehkan di seluruh situs. Kurangnya
pengamatan sistematis diobat take membuat
kasus pengobatan mandiri dan nonkepatuhan semua lebih mencolok dan
menyoroti kebutuhan untuk lebih lanjut
analisis sistematis.
Kesimpulan
Responden umumnya dihargai ITN malaria
pencegahan, bagaimanapun, ketersediaan
dan biaya yang hambatan untuk ITN
kepemilikan. Pengaturan tidur, kondisi iklim
dan memprioritaskan bayi menyebabkan
ketidakkonsistenan
ITN
menggunakan
during kehamilan. Pesan kesehatan bisa
mengatasi adalah- tertentu menggugat,
misalnya, jika ITN yang tidak digunakan
selama kehamilan sehingga mereka item
baru untuk menandai kelahiran seorang anak.
Sebaliknya, kesadaran IPTp bervariasi
terutama di situs dan, bersama dengan
pengalaman masa lalu dari sisi effects,
rendahnya kesadaran berkontribusi, untuk
non-kepatuhan meskipun IPTp tidak selalu
disampaikan di bawah DOT, kepatuhan
adalah umum dan ini terkait dengan
perempuan upaya keseluruhan untuk
mengikuti petunjuk dari petugas kesehatan
dan evaluasi positif dari ANC sebagai paket
intervensi.
Tes diagnostik malaria tidak selalu

tersedia, tetapi mengkonfirmasikan diagnosis
malaria melalui tes darah adalah umumnya
dihargai. Namun, ada contoh berlebihan
pengobatan di Ghana dan Malawi: di Ghana,
ini mengakibatkan dari salah tafsir dari
kebijakan nasional, yang mengilustrasikan
trates perlunya pemantauan pelaksanaan
lokal. Misalnya diri pengobatan dan nonkepatuhan dengan pra Kursus pengobatan
jelaskan terkait dengan lokal yang luas
penyakit yang tumpang tindih dengan
malaria,
biaya
dan
memanfaatkankemampuan
anti-malaria
di
fasilitas
kesehatan
dan
individu
preferensi
berdasarkan pengalaman masa lalu dan saat
ini obat-obatan. Pesan kesehatan harus
karena itu juga membahas kepatuhan
terhadap diresepkan obat antimalaria serta
discouraging pengobatan mandiri.
Rincian penulis
1
Centre for Social Science and Global Health,

University of Amsterdam, Amsterdam, The
Netherlands. 2Centre de Recerca en Salut
Internacional de Barcelona (CRESIB, Hospital ClnicUniversitat de Barcelona), Barcelona, Spain.
3
Departamento de Antropologa Social, Universidad
Complutense de Madrid, Madrid, Spain. 4Department
of Community Health, School of Medical Sciences,
Kwame Nkrumah University of Science and
Technology, Kumasi, Ghana. 5College of Medicine,
University of Malawi, Blantyre, Malawi. 6Navrongo
Health Research Centre, Navrongo, Ghana. 7The
Kenya Medical Research Institute (KEMRI) and
Centers for Disease Control and Prevention (CDC)
Research and Public Health Collaboration, Kisumu,
Kenya. 8Research and Development Division, Ghana
Health Service, Accra, Ghana. 9Division of Parasitic
Diseases and Malaria, Centers for Disease Control
and Prevention (CDC), Atlanta, GA, USA.
Received: 5 September 2013
Accepted: 10 November 2013
Published: 20 November 2013

JOURNAL READING - Malaria Dalam Kehamilan

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JOURNAL READING - Malaria Dalam Kehamilan

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Prevention and Management of Malaria during Pregnancy: Findings from A

Disusun untuk memenuhi tugas kepaniteraan klinik

FAKULTAS KEDOKTERAN UNIVERSITAS JEMBER

Pell et al. Malaria Journal 2013, 12:427

Prevention and management of malaria during

Pell et al. Malaria Journal 2013, 12:427

the MiP Consortiums Anthropology Team. This article

The study incorporated one country from each of the

Pell et al. Malaria Journal 2013, 12:427

with different patterns of malaria transmission; and to

Livelihood activities include subsistence farming of maize,

An anthropological approach was taken to data collection.

Free listing and sorting

Focus group discussions

Pell et al. Malaria Journal 2013, 12:427

using free-listing and sorting exercises, the research team

Five main categories of respondents were interviewed

At each site, a first phase of data analysis ran in parallel

Overall ethics clearance was obtained from the Clinical

Sleeping under an ITN was generally recognized as the

Pell et al. Malaria Journal 2013, 12:427

Availability and use

Free delivery at health facilities

Pregnant women report sleeping under ITNs

Free delivery at health facilities

Pregnant women report sleeping under ITNs

Sold in health facilities at subsidized prices

Cases of seasonal use of ITNs

Sold in health facilities at subsidized prices

Pregnant women complain about costs of ITNs

Availability and access of ITNs

In Ghana, ITNs were sold in the health centres at ANC

Pregnant women report saving for use after delivery

netting, fishing nets, latrine doors, crop protectors and

Policies regarding IPTp delivery varied across the sites:

ITN ownership and use

At all sites, pregnant women reported a demand for

In central Ghana and Kenya, pregnant women did not

Pell et al. Malaria Journal 2013, 12:427

Kenyan pregnant women were often unfamiliar with

Attitudes towards IPTp

The lack of awareness of IPTp in Kenya and central

I: Do you think that those medicines have disturbed

Observations highlighted how IPTp was not universally

Pell et al. Malaria Journal 2013, 12:427

Although generally positive, attitudes towards and

I: Did you not have malaria at a point in time?

Pell et al. Malaria Journal 2013, 12:427

pregnant women, but the rapid diagnostic test confirmed a

you are doing your research, and doing the blood

Anti-malarials, including SP, were available in drugstores

Pell et al. Malaria Journal 2013, 12:427

malaria. In Kenya, the majority of pregnant women and

In Ghana, pregnant women did not recall the names of

provided. However, ANC was not offered at that time, and

Pell et al. Malaria Journal 2013, 12:427

One multi-site study in Kenya highlighted additional

been identified in The Gambia [27] and Uganda [29].

Pell et al. Malaria Journal 2013, 12:427

negative test result were disappointed when they did not

with regard to malaria interventions, are limited by several

Pell et al. Malaria Journal 2013, 12:427